The airbus A320 family fan cowl door safety modification: a human factors scenario analysis

Abstract

Purpose-The Airbus A320 family engine fan cowl doors safety issue is known to the industry for almost 18 years, however it has not been addressed adequately by the aircraft manufacturer and the various operators and regulating authorities. This brief case study paper examines in a systematic way the possible operational and safety implications of a new modification on the engine fan cowl doors. Design/methodology/approach-An array of error-prone scenarios are presented and analysed under the prism of human factors in a non-exhaustive qualitative scenario analysis. Findings-All examined scenarios are considered more or less probable. A number of accident prevention solutions are proposed for each of the scenario examined, in view of the acceptance and implementation of this modification by operators. Research limitations/implications-Since these scenarios are neither exhaustive, nor have been tested/validated in actual aircraft maintenance practice further analysis is necessary. A substantial follow up survey should take place, which should include a wider array of scenarios. This would allow obtaining the necessary data for a quantitative (statistical) analysis. Practical implications-This case study identifies issues in relation to this modification, introduced by Airbus and the European Aviation Safety Agency (EASA), which may prove problematic from the point of view of safety effectiveness and disruption of operations. Originality/value-This case study examines a long-standing aviation safety issue and the implications of a solution proposed by the aircraft manufacturer and adopted by EASA. This can be useful in increasing the awareness around these issues and highlight the importance of a human-centric and scenario-based design of engineering modifications towards minimising error in aircraft technical operations.

A Preliminary Investigation of Maintenance Contributions to Commercial Air Transport Accidents

“…One of the 'planes' in Reason's (1990) original iteration of the Swiss Cheese model was labeled "fallible decisions", Kourousis, et al [40] identified the increased defenses the manufacturer of the A32X series of aircraft inserted into the safety system in the aftermath to this accident in an effort to reduce or eliminate the occurrences of cowl doors not being fully latched at take-off. Mandated modifications included new hardware and new procedures.…”

“…Mandated modifications included new hardware and new procedures. However, the authors noted the potential latent failings that could arise from these newly implemented modifications [40]. These latent conditions arising from fallible decisions made by people who are not proximal to the accident may hinder or even work directly against the desired effect of reducing the number of cowl door incidents the mandated modifications are seeking.…”

The Diagnosis of Communication and Trust in Aviation Maintenance (DiCTAM) Model

“…For this purpose, the case study presented next is selected to present the operation of the DiCTAM model, as well as exemplifying its use. A well-known case has been selected, that of the engine fan cowl door losses experienced in the Airbus A320 family fleet in worldwide level [56]. The method of the case study is considered to be suitable method to examine hypothetical scenarios.…”

“…The method of the case study is considered to be suitable method to examine hypothetical scenarios. A suitable application for the prediction exercise is deemed the use of the Fan Cowl Doors (FCDs) maintenance occurrences (after the implementation of the new procedures, provisioned by the latest EASA Airworthiness Directives (ADs)) [56]. The case study methodology assists in the holistic examination of these hypothetical occurrences to unveil concealed elements and identify or even predict future trends or patterns [57].…”

“…At this stage the aim is to examine these hypothetical scenarios for the identification of communication and trust elements and then, based on these findings, to predict the possibility of occurrence of each scenario. Seven scenarios, as they were introduced and discussed by Kourousis et al [56], are examined below for the identification of trust and communication elements. Each scenario is scrutinised against the items of the CTQS by the author as SME, for the identification of a question set's items within the scenario.…”